Registering disapproval

For people requiring care, personal assistants are a lifeline. But new research on the views of the employed and employers reveals that the two sides could be heading for conflict over regulation. By David Brindle

Simon Stevens, a disability consultant who has cerebral palsy, with his personal assistant Flora Lloyd at home in Coventry. Photograph: Anita Maric/News Team International

Does personalisation of care and support services inevitably mean casualisation of the paid workforce? The question has been bubbling under the debate on self-directed support, but this week bursts into the open with publication of the largest research study into users of services as employers.

There are already an estimated 76,000 people in England employed as personal assistants (PAs) by recipients of direct payments. That number will soar further if personal budgets take off in a big way, raising profound questions about how the system should be regulated and how much protection should be afforded employee and employer.

It is an issue that exposes a fault line at the core of the personalisation agenda: can the demands of young, disabled service users, who want freedom to employ who they wish, be reconciled with the interests of older and more vulnerable people - and, indeed, most PAs - who want the security of a controlled system?

The new research comes from Skills for Care, the sector workforce agency, and is based on 526 face-to-face interviews with direct payment users who employ PAs, and questionnaires completed by 486 of the PAs, of whom 100 then took part in a more detailed survey by telephone. Overall, the findings suggest that the system is working well, with relatively high levels of satisfaction on both sides of the relationship.

Almost four in five employers (79%) said they were very satisfied with the care and support they received from their PAs. Exactly half had previously been getting services provided directly by the local authority and, of this group, just 26% had been very satisfied with them. Thirty-six per cent had experienced lateness of service (compared with 6% under a PA system), 34% poor quality service (2%), 33% inflexibility (5%), and 31% failure to turn up without notification (5%).

Under direct services, 13% of recipients said they had suffered psychological abuse (6% under a PA system), 9% financial abuse (5%), 3% physical abuse (1%) and 2% sexual abuse (less than 1%) - although it should be noted that people typically had used direct services for longer.

Frequently appreciated

Among PAs, a striking 95% declared themselves happy with their role, and 90% felt appreciated either most of the time or frequently. Two-thirds had previous experience of working in health and social care and, of them, 66% said they had chosen to work as a PA because of the convenient or flexible hours involved. Hours were variable in 56% of cases surveyed.

One in five PAs thought they were required to work too many hours, and one in three considered themselves underpaid. The average hourly wage was £7.60, with 11% of roles paying more than £10 and 8% paying less than £6. The typical PA would take home about £165 a week.

For Skills for Care, the main worry thrown up by the research is a general reluctance on the part of employers to arrange or fund training for their PAs - only 7% having done so. Andrea Rowe, the agency's chief executive, says: "My feeling is that the stock answer of employers who struggle with the complexity of training and qualifications is to hide behind 'we don't think they need it'. There is some responsibility on us to make sure that the framework and supply of training and skills development is simple for them and is affordable."

But this starts to expose the tension within the model. Asked what attributes they considered very important for recruiting a PA, 89% of employers said a friendly attitude and 77% an ability to adapt to their needs, but only 60% said good references, 32% a willingness to learn and engage in training, and 28% having experience in health or social care. Barely a third (34%) of PAs had been given a job description and, significantly, almost half had been known to their employer before being taken on.

The study, carried out by IFF Research, was co-sponsored by the General Social Care Council (GSCC), which is to launch a consultation on the potential regulation of PAs with a view to making recommendations to ministers by the end of the year. The debate that this will trigger is likely to polarise opinion.

In the research, 79% of employers said registration of PAs would be either very or quite useful. But only 46% thought it should be compulsory and, when asked a different question, 71% wanted to retain the right to employ somebody who was not registered. Among PAs, on the other hand, 87% thought registration would be a very good or fairly good idea.

Lady [Jane] Campbell, chair of the Commission for Equality and Human Rights's disability committee, employs PAs and is trenchantly opposed to a compulsory register. "I have employed people who would not have been registered in a million years," she says. "My former driver was imprisoned for 18 years for armed robbery; I did him a lot of good and he did me a lot of good. My current driver has special needs, and one of my PAs has mental health issues."

Giving people second chances and fresh starts in life is an important part of being a social care employer, Campbell argues. "I know the risks and I judge that I am less at risk from a PA than some stranger from a [care] agency. Having to use a register suggests that we are all vulnerable people. Well, I am not."

Rowe says talks have been taking place at the Department of Health around the idea of different levels of registration for different levels of care and support. "That wouldn't detract from the need for those people delivering personal care - very personal care - to people in their own homes to be . . . checked and properly inducted and trained."

David Behan, the department's director general of social care, seems to reflect this when he talks of "a much more differentiated and targeted approach". And the GSCC itself appears keen to avoid an overly restrictive solution. Mick Lowe, its director of strategy, says: "If there is to be some form of registration, it's got to be one that still enables people to have choice."

Behan is at pains to stress, however, that the first step must be to reappraise precisely what registration is for. "I believe we have conflated safety and quality in our thinking over the past few years and the debate about quality [of service] has played second fiddle to the debate about safety. I think we need to square that off in some way."